Field of the Invention
The invention relates to methods and apparatus to differentiate between histologically normal and histologically abnormal tissues, and to differentiate neoplastic tissue from histologically abnormal non-neoplastic tissue.
Screening for Cervical Intraepithelial Neoplasia (CIN)
Although there has been a significant decline in the incidence and mortality of invasive cervical carcinoma over the last 50 years, there has been an increase in both the reported and actual incidence of CIN. As a result, it has been estimated that the mortality of cervical carcinoma may rise by 20% in the years 2000-2004 unless screening techniques for CIN are improved.
Present screening for CIN and cervical cancer is relatively inexpensive but labor intensive because it initially relies on the results of a Pap smear; a false negative error rate of 20-30% is associated with insufficient cell sampling and/or inexpert reading of Pap smears. , Given an abnormal Pap smear, colposcopic examination of the cervix (with a magnifying lens) followed by colposcopically directed biopsy and histologic examination of the tissue sample can provide a diagnosis of CIN. Histologic confirmation of the diagnosis, while relatively time-consuming and expensive, is necessary because the accuracy of classification among abnormal tissues by colposcopy alone is limited, even in experienced hands.
Improving the predictive value of colposcopy in distinguishing CIN from other abnormal tissues (e.g., tissue infected with human papilloma virus (HPV) or inflammatory tissue) could reduce the required number of biopsies and thereby increase the speed and efficiency of the screening process. Diagnosis and treatment might be combined in a single office visit, with colposcopically directed treatments including loop electrosurgical procedures (LEEP), cryo and laser therapies, and chemopreventive agents. Further, explication of improved methods to classify tissue as normal or abnormal, while not leading directly to a diagnosis of CIN, would reduce costs by allowing performance of colposcopy by medical technicians less skilled than trained colposcopists (usually physicians).
Spectroscopic Methods in Colposcopy
Spectroscopic methods for differentiating cervical neoplasia from normal cervical tissue in vivo have been described. The methods rely generally on observations that the fluorescence of abnormal tissue is significantly weaker than that of normal tissue at several excitation wavelengths, e.g., 330, 350 and 450 nm. This property has been used for spectroscopic identification of histologically abnormal tissue. For example, in vitro fluorescence intensity comparisons at an excitation wavelength of 330 nm yielded positive predictive value, sensitivity and specificity of 86%, 88% and 75% respectively on colposcopically normal and abnormal biopsies from the same patient. Differences between neoplastic (CIN) and non-neoplastic abnormal tissues (intimation and HPV infection) yielded the largest spectroscopic differences at an excitation wavelength of 330 nm.
Additionally, fluorescence spectra have been measured in vivo to detect neoplastic tissues in different organ systems. A variety of methods for making such determinations have been proposed. For example, ratios of autofluorescence intensity at two different emission wavelengths have been used by many groups, and scores based on multi-variate linear or non-linear regressions and fits to extract concentrations of various chromophores have been proposed by many others for inclusion in decision criteria.
In one application, 337 nm wavelength excitation was applied to colonic tissue. Multi-variate linear regression analysis was used to correctly distinguish adenomatous polyps from normal colon and hyperplastic polyps with positive predictive value, sensitivity and specificity of 86%, 86% and 80% respectively.
Tissue Classification Methods
Previous attempts to reliably distinguish CIN from intimation or HPV infection in vivo using colposcopy alone have been unsuccessful. Fluorescence intensity may be useful in this regard, but is not sufficient in itself because analogous fluorescence intensity measurements of the same tissue type may vary by more than a factor of two from patient to patient, and by about 15% within the same patient. Methods relating fluorescence intensities from abnormal and normal tissues of the same patient, however, tend to be more predictable and therefore more diagnostically useful.
Thus, in general, each patient must serve as her own control. Considering cervical tissues in a given patient excited with 337 nm wavelength electromagnetic excitation, tissues with HPV infection are less fluorescent with than tissues with chronic inflammation, and tissues with dysplastic changes exhibit even lower fluorescence than those with HPV infection. The lowest level of fluorescence (relative to analogous fluorescence measurements on other tissue types in the same patient) is exhibited by tissues with the most abnormal form of CIN. Analogous relationships among tissue fluorescence intensity measurements in a patient may exist if excitation wavelengths other than 337 nm are used because the shape and intensity of cervical tissue spectra do not change substantially when the excitation wavelength is increased or decreased by less than 10 nm.
Additional information useful for tissue classification may be found in the peak emission wavelength of tissues with CIN, which is positively correlated with the peak. emission wavelengths of normal tissue spectra from the same patient. This relationship, however, is not observed for tissue samples with inflammation or HPV infection.
Thus, a reliable method to spectroscopically classify tissue as normal or abnormal, and in the latter case to distinguish inflammation or HPV infection from CIN, is needed. Such a method could rely on one or more of the relationships described above, augmented with additional information indicative of the particular separation or classification desired.